Introduction
Opioids are a wide class of drugs that includes controlled, illegal substance heroin, synthetic opioids (fentanyl), and subscription drugs for pain relief such as oxycodone (registered as OxyContin®), hydrocodone (registered as Vicodin), codeine, morphine, and many others. The primary effect of opioid use stems from the drug’s interaction with opioid receptors located on nerve cells in the human body and brain. Opioids are effective for treating persistent and severe pain and generally considered to be safe, assuming that a patient takes them for a limited period of time and strictly follows their doctor’s recommendations.
The danger lies in the side effects of opioids: concurrently with pain relief, this type of drug gives patients a sense of euphoria. Because of the need for euphoric sensations or developing resistance toward the drug, some patients take opioids for inappropriate purposes, in larger quantities than prescribed, or without a prescription at all. Today, it has been established that regular use of opioids — even when controlled by a doctor — can cause dependence. In the event of abuse, addiction, overdose incidents, and deaths are tragic but not uncommon outcomes.
As reported by the National Institute on Drug Abuse (2020), in 2018, opioid addiction was taking the lives of 128 people every day. That same year, approximately 1.7 million people reported an opioid misuse disorder. The misuse of opioids and systemic failures to control their use and distribution has led to the point where it is not an exaggeration to say that opioid addiction reached epidemic status in the United States. The National Institute on Drug Abuse (2020) estimates that opioid misuse costs the United States as much as $78.5 billion a year. This tremendous figure includes immediate healthcare costs, lost labor productivity, addiction treatment, and the involvement of the criminal justice system. Because some women continue to use opioids during pregnancy, their children are at risk of developing neonatal abstinence syndrome. Aside from an increase in injection drug use is generally associated with the spread of infectious diseases, with the most dangerous of them being HIV and hepatitis C.
The National Institute on Drug Abuse (2020) provides statistics regarding opioid use in the United States. According to the institution, two to three patients out of ten patients who are prescribed opioids by their doctor to treat chronic pain misuse them. As many as 8-12% of patients end up suffering from an opioid use disorder. For a small fraction (4-6%) of people who misuse opioids use them as a gateway drug to heroin. In turn, four out of five people who suffer from heroin addiction started with prescription opioid drugs.
The question arises as to how the situation with opioid use has come to be what it is now. The National Institute on Drug Abuse (2020) explains that in the late 1990s, pharmaceutical companies pushed their agenda, insisting on the safety of prescription opioid pain relievers. The medical community was convinced, and opioid drug prescription became a common practice and ubiquitous. By the 2000s, it became clear that opioids were highly addictive, but by that time, the country had already been ushered into a public health crisis.
Public Health Issue Analysis
The ongoing opioid epidemic in the United States is a result of many interlocking factors and an issue that does not have any easy, straightforward solution. Jones et al. (2018) explain that before 1800, the medical community in the West did not regulate the use of cocaine and opioids. They were freely marketed and prescribed to treat a variety of health issues, ranging from diarrhea to toothache. Starting with The Harrison Narcotic Control Act of 1914, the public sentiment shifted from acceptance to “opiophobia,” which dominated the first half of the 20th century. The first milestone in the development of the opioid crisis was the publication of small-sample studies allegedly proving that the therapeutic use of opiate analgesics barely ever results in addiction.
At the same time, leading American and international health institutions such as the World Health Organization, the American Pain Society, and the Veteran’s Health Administration were advocating for better pain management. Physicians were rightfully wary of the liberal use of analgesics, but their resistance was soon assuaged by two historically significant statements by The Federation of State Medical Boards and the Drug Enforcement Agency (McCormick, 2019). Pharmaceutical companies were pushing for more use of prescription opioids, which was largely done without proper attention to safety issues. Ultimately, it was the culture change that now saw not using opioids for pain relief as unprofessional and inhumane that opened floodgates to an inevitable crisis.
Today, modern research suggests that some individuals are more at risk of developing an opioid use disorder than others. Webster (2017) cites a recent National Health Interview Survey that shows that 126.1 million US adults suffered from some pain over the course of the last three months. Out of those, 11.2% reported daily pains, and 10% described their pain levels as severe. According to Wester (2017), the problem of opioid misuse arises from a variety of factors. It may be a misunderstanding between the patient and healthcare worker, which might be further exacerbated by language discordance. Some patients are motivated by the desire to avert abstinence syndrome or experience euphoria or other psychoactive rewards.
Webster (2017) states that before prescribing opioid medications, every provider needs to screen a patient for risk factors such as insufficient social support, personal or family history of substance abuse, psychological stress, trauma, or disease, and history of legal problems. It is essential to also consider risk factors for overdose mortality related to opioids that are still on the rise in the United States as cited before (Webster, 2017). Such risk factors include but are not limited to middle age, unemployment, comorbid mental and physical disorders, methadone use, and co-prescription of benzodiazepine and antidepressants. Lippold et al. (2019) report that all racial/ ethnic groups and both sexes have seen an equal increase in opioid use and, therefore, opioid misuse rates.
Some of the key agents in providing a response to the ongoing opioid crisis are the U.S. Department of Health and Human Services (HHS) and the National Institute of Health (NIH), which is a component of the HHS (The National Institute on Drug Abuse, 2020). The NIH is the country’s leading medical research agency that is working on developing new and better ways to prevent and treat opioid use disorders. The NIH meets with academics and pharmaceutical companies to discuss pain management. The HHS sets larger goals and sets priorities such as improving access to recovery services or promoting the use of drugs that reverse an overdose. The actions undertaken by the HHS and NIH can be interpreted with the public health theory of change (ToC). The ToC focuses on the long-term outcomes (such as priorities set by the HHS) and designs a process that allows to achieve them.
Program of Intervention Analysis
The opioid epidemic is addressed at various levels: international, national, and local. For this assignment, the Naloxone Co-Payment Assistance Program (N-Cap) that focuses on opioid overdose through co-paying for overdose-reversing drugs will be discussed. The program was launched in New York State in 2017 as a response to a soaring mortality rate from opioid use disorders. Launching the program was mainly possible due to the efforts and leadership of the New York State Health Department. N-Cap is consistent with one of the key goals set by the NYS Health Department (2018) as per a recent publication on its official website: “providing resources to assist communities in combating the opioid epidemic at the local level.”
Naloxone is a drug that is a lifesaver for a person who is at risk of dying from an opioid overdose. As stated by the NYS Health Department (2018), naloxone is an emergency medicine that is available through a “standing order” at participating pharmacies. This means that a person in need can receive this drug without a prescription from their doctor. Unemployment and poor social support are some of the risk factors for opioid misuse, and it is readily imaginable how an opioid addict might not be able to pay for Naloxone. N-Cap covers up to 40% in prescription copayments to eliminate out-of-pocket expenses. That is the crux of the program: it makes an emergency drug available to reduce mortality among the most vulnerable social demographics. N-Cap is a logical successor of the previous strategy that sought to provide free naloxone distribution and training at 65% of registered Opioid Overdose Prevention Programs.
Despite the efforts made by the NYS Health Department (2018), the opioid epidemic in the state still persists. If in 2017, the crude death rate from opioid overdose was 15.6 people per 100,000 population, in 2018, it reached 16.8 people. Similarly, deaths from synthetic opioids increased from 8.6 people in 2017 to 11.3 people in 2018. All emergency department visits (including outpatients and admitted patients) involving heroin overdose is another concerning indicator: the number rose from 56.7 in 2017 to 63.2 in 2018. These figures show that in the first year after launching the program, not much progress had been made.
A public health behavioral theory that may be used to analyze the selected prevention program is the social cognitive theory. Developed by Bandura, the social cognitive theory describes how a person alters their behavior as a result of observing others. The most relevant aspect of social cognitive theory in light of the subject matter is self-efficacy, or belief in one’s ability to manage difficult situations (Shamaizadeh et al., 2019). N-Cap is a potentially effective program because it shows people that they can access resources to overcome adversity.
It is difficult to say exactly what obstacles prevent N-Cap from reaching its full potential. One of the possible reasons might be the lack of awareness that has been found to be one of the primary risk factors for opioid abuse (Wilder et al., 2016). Individuals still have knowledge gaps about opioid use and risks, let alone about resources that might be life-saving in an event of overdose. From the standpoint of social cognitive theory, these people do not have enough positive examples to follow. Potentially, if N-Cap could use better marketing and other tools for raising awareness, it could influence people and their behaviors and help them improve their quality of life.
Future Outlook
The opioid epidemic is a complex problem that cannot be solved overnight. The logical question arises as to what the prospects of its future development are right now and whether the situation will improve in the nearest future. Investigators at the Massachusetts General Hospital (MGH) Institute for Technology Assessment are pessimistic about their predictions. The scholars are expecting the opioid crisis in the United States only to worsen in the years to come. According to their research, the annual number of opioid overdose deaths will jump from 33,100 in 2015 to 81,700 in 2025, which will mean a 147% increase (Chen et al., 2019).
Jagpreet Chhatwal, Ph.D., of the MGH Institute for Technology Assessment (MGH-ITA), attributes the ongoing trends in the opioid epidemic to the changing nature of opioid use in the country. Chhatwal explains that the crisis broke out in the 1990s because the medical community sought to respond to pain management problems while disregarding safety issues (Chen et al., 2019). However, today, while prescription opioid overdose rates do not show significant increases nationwide, there is a surge in overdose deaths due to heroin (Chen et al., 2019). The main implication from these observations is that older prevention programs might be no longer relevant in fighting the epidemic as it is ever-evolving.
The US Department of Health and Services (2018) continues to address the social determinants of health that shape the outcome in terms of opioid use safety. Probably, the most important social determinant of health is access to healthcare that can be impeded by many social and behavioral factors. The poverty rate in the US is at 11.8%, and it is expected to worsen due to the economic and social effects of the COVID-19 pandemic. 60 million people live in rural areas where there might not be enough hospitals and those that do exist might be understaffed and underfunded. As for behavior factors, poor awareness of opioid use risks leads to purposeful or inadvertent abuse. Based on these facts, it is important to extend medical coverage to improve access to health services, build better infrastructure in remote areas, and continue educating communities at risk.
Conclusion
The US opioid epidemic is a public health issue whose death toll is projected to rise in the nearest future. The crisis started in the late 1990s when opioid medications became not only publicly available but also promoted as a safe and easy way to manage chronic, severe pain. The US government agencies still seek ways to tackle the epidemic, one of which is improving access to drugs that reverse overdose such as Naloxone. This paper discusses the Naloxone Co-Payment Assistance Program (N-Cap) that shares or eliminates costs for patients receiving Naloxone from participating pharmacies in New York State. As a practicing health professional, I will need to scan my patients carefully for risk factors before prescribing opioid medications and make sure that they only use them for a short period of time. In addition, I intend to educate them about the dangers of opioids and refer them to resources that could help them in case they already struggle with dependency.
References
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